d i s a b i l i t y a n d r e h a b i l i t a t i o n , 1999; v o l . 21, n o s . 10± 11, 459± 468

The research base of community-basedrehabilitation

REG MITCHELL*

Senior Lecturer, Department of Behavioural Sciences, Faculty of Health Sciences, University of Sydney,

PO Box 170, Lidcombe, NSW 2141, Australia

Summary

This paper provides an overview of the current research oncommunity-based rehabilitation (CBR) which can be found inthe public domain. A brief background to the concept of CBRis given, and it is shown how much of this published researchre¯ ects the fundamental principles of CBR service delivery,technologytransfer, community involvement,and organizationand management. Speci® c research is discussed under theseheadings. Additional topics reviewed include the target popu-lations of, and disabilities addressed in, CBR research, and theepidemiology of disability. A summary of locations where theresearch has taken place is also presented. It is concluded that,while there is still a need for additionalresearch and evaluationin the extensive ® eld of CBR, there has been some reluctance toeither undertake or permit such activities. However, CBR andultimately the disabled can only bene® t from placing researchand evaluation of CBR into the public domain.

Introduction

It is estimated that at least 7% of the world’ s

population suŒer from various types of physical or

mental disabilities. This rate of disability prevalence is

expected to increase because of the decline in mortality

rates of disabled people and the increase in the

proportion of elderly persons in the world’ s population.

Recognized by world authorities as early as 1950,

disability has now emerged as a major worldwide health

problem. " Chermak " reported that disability is now

recognized as a problem common to nations with

disparate levels of socioeconomic development.

In the past, rehabilitation projected an image of a

person in a wheelchair or with a prosthesis. Rehabilitees

were perceived as requiring long-term institutional care

in either hospitals or special centres. This often long-

term institutionalization resulted in the isolation of many

disabled persons from the mainstream of community life

and activities. Institution-based rehabilitation is very

costly and provides no more than about 3% of the

rehabilitation needs of individuals and populations.

* e-mail: R.Mitchell! cchs.usyd.edu.au

The failure to meet the rehabilitative needs of the

majority of disabled persons through existing traditional

services, subsequently highlighted by Periquet, # resulted

in the World Health Organization (WHO) developing an

innovative approach to the delivery of rehabilitation

services. The WHO approach came to be known as

community-based rehabilitation (CBR).

Background

In May 1950 the third World Health Assembly called

for the development of a rehabilitation programme for

the physically handicapped. In 1966, at the 13th World

Health Assembly, a resolution was adopted which

stressed the importance of rehabilitation and urged

member states to develop their rehabilitation services as

an integral part of the national health services. Ten years

later, in 1976, the World Health Assembly adopted a

resolution encouraging the application of eŒective and

appropriate technologies to prevent disability while

integrating prevention and rehabilitation into the health

programme at all levels, including primary health care.

Thus, the concept of CBR started to develop in the

WHO through the primary health care approach.

The WHO, in the formative years of CBR, established

the term for situations in which resources for rehabili-

tation were available in the general community. The

ideal was that there would be a large-scale transfer of

knowledge about disabilities and the skills in rehabili-

tation to the disabled, their families, and members of the

community. There was also an expectation that the local

community would be actively involved in planning,

decision-making, and the evaluation of their CBR

programme. `One might call this a democratization of

rehabilitation.’ $

In 1988 the WHO Regional O� ce for the Western

Paci® c sponsored a workshop on applied research into

CBR.% The working group at this workshop noted that

CBR had proved to be eŒective and acceptable as an

approach to delivering basic rehabilitation services.

Disability and Rehabilitation ISSN 0963± 8288 print} ISSN 1464± 5165 online # 1999 Taylor & Francis Ltdhttp:} } www.tandf.co.uk} JNLS } ids.htm

http:} } www.taylorandfrancis.com} JNLS } ids.htm

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R. Mitchell

However, it was also noted that, although there were

basic guidelines available on service delivery, technology

transfer, community involvement, and organization and

management, there was little or no published research on

these and other aspects of CBR.

Research in CBR

Research and evaluation has not been a prominent

feature of the CBR movement. This is understandable in

the context in which CBR has been developed and

implemented. Resources, both ® nancial and in the form

of skilled manpower, have always been limited. The need

has been so obvious and pressing. In this context it

would be accurate to observe that no country could

contend that it has satisfactorily met all its rehabilitation

demands and so was now able to direct some of its scarce

resources into evaluation. In general, both government

and non-government agencies have been so stretched in

committing resources to the implementation of CBR that

research and evaluation has taken second place.

In addition it would be unfair to attribute something

of a missionary zeal to the proponents of CBR. Amongst

those most enthusiastic and committed to CBR there is

a conviction that this approach is the answer to current

needs, and all energies and resources must be devoted to

its successful implementation. At the same time govern-

ment and non-government agencies, once committed to

the establishment of a CBR project, are naturally not

anxious to have this commitment questioned.

This tendency to view evaluation as potentially critical

and perhaps destructive is unfortunate. There needs to be

a recognition of, and emphasis that, there is a positive

side to evaluation which includes identifying the potential

for improvement.

It is evident, however, that even from its early stages of

implementation CBR has been the focus for some form

of evaluation. The 14 countries that met in Sri Lanka in

1982 did so to report on varying degrees of ® eld testing

of the ® rst version of the WHO manual. The record of

the various countries reports & is, however, generally

limited to such matters as initial consultant visits,

training workshops held, and numbers of clients involved

in training. Country representatives reported in varying

detail on ® eld-testing projects ranging from merely a few

months to up to 2 years. Overall results reported that

some 73% of clients improved with CBR training. The

most common reasons for failure were inability to ® nd a

suitable trainee, shortness of training time, and with-

drawal of clients from the programme. There were some

critical comments regarding the technical information in

the training packages, as well as problems with the text

and drawings.

The Rehabilitation Unit of WHO Headquarters

produced a comprehensive report on CBR. ’ In a

summary report of the African Regions (nine countries),

the American Region (11 countries), the Eastern

Mediterranean Region (six countries), the European

Region (four countries), the South East Asian Region

(seven countries), and the Western Paci® c region (six

countries) only two of the 43 country reports mentioned

any research evaluation.

This is not to conclude that evaluation and research

into CBR has not taken place. It is however, a fair

assumption that results of such research have not been

formally reported. Where formal reports have been

prepared these have inevitably been directed to what is

colloquially called `in-house ’ sources. Reports directed

to funding agencies, the WHO HQ Rehabilitation Unit,

supporting government and non-government agencies

and the like have a natural tendency to be positive.

Likewise the recipients of such reports are usually

supportive and often committed to the success of the

projects under study.

This present article aims to review the research

published on CBR to date. The WHO % report suggested

four basic features of CBR that were amenable to the

formal processes of research and that these be considered

as high research priorities Ð service delivery, technology

transfer, community involvement, and organization and

management. However, some of the literature has

revealed that the epidemiology of disability in certain

countries and for certain disabilities was, and still tends

to be, sadly lacking.

Organization and management

The idealized CBR model concerns many people. The

local supervisor, family trainer, other members of the

family, the disabled person, the community, all are

expected to be actively involved in the rehabilitation

process. Because people are the fundamental component

of CBR, organization plays a signi® cant role in ensuring

the eŒectiveness of a CBR programme. Management

occurs both at the horizontal level (local supervisor,

family member, disabled person, the community) and the

vertical level (referral structures from the village} town,

province, district, national, international).

One of the early non-WHO reports on CBR in action(

examined the success of a rehabilitation and activation

programme for elderly and disabled nursing-home

patients. This evaluation, conducted over 2 years,

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reported few positive results and many di� culties. One

of the major problems identi® ed by this author was the

lack of acceptance into the `mainstream ’ health-care

system. A somewhat related problem was also identi® ed

by Clarke,) who noted that in Britain there was still a

need to integrate medically provided service delivery

with social services. However, it must be noted that the

programmes reported on by Kivela ( and Clarke) were

operational in developed countries where health and

social service infrastructure diŒered markedly from that

in developing countries.

These problems of integration of services have subse-

quently been re¯ ected in WHO reports, and attempts at

their resolution in developing countries are re¯ ected in a

number of papers in this special issue. However, as

recently as 1990 Chermak " stated that, despite clear

indication from the WHO that there must be an

integration of service delivery within any national

development strategy, many countries have failed to

achieve this integration. This author goes on to state that

CBR, if implemented correctly, would reverse this policy

failure and the consequent inequalities and social

injustice.

However, despite the dismal picture presented by

Chermak " there are reported examples of successful

integration and service delivery to the disabled in their

home environment. A number of examples can be found

in this special issue and an additional example has been

described by Maryniak et al.* These authors also

reported that CBR demonstrated a more e� cient

utilization of resources, together with a cost saving in

tertiary care. Included in the overall cost saving was the

travelling time for patients.

Cost-eŒective delivery of rehabilitation services for

people in the community using the CBR approach has

also been reported. " ! This report concluded that CBR

was highly eŒective for both children and adults, and

yielded similar results in diŒerent types of society. The

recruiting of volunteers and mobilizing community

resources resulted in low cost and also promoted the self-

esteem of the disabled.

Technology transfer

The concept of technology transfer includes the

technical skills that each person at each level (vertical

and horizontal) should possess in order to deliver

eŒective rehabilitation. Included among these skills will

be the materials, such as the WHO manual,$ used to

transfer skills. Other skills previously identi® ed include

designing, producing and maintaining appropriate aids,

packaging `rehabilitation technology’ other than in

written form, and identifying various disabilities through

the application of simple detection techniques.

One of the requirements for successful implementation

of CBR, especially into developing countries, has been

that locally available materials and technology be used in

rehabilitation delivery. The problems " " associated with

failing to comply with this are the di� culty of sustaining

supply from outside the country, lack of local training in

technology manufacture and the utilization and main-

tenance of the equipment at the workface.

Community involvement

Community involvement is a vital ingredient in the

implementation of a CBR programme. Training of the

disabled person should be the concern not only of the

family trainer and local supervisor but also the com-

munity in which the disabled person lives. Issues that

emerge include attitude change towards the disabled in

their community, mobilizing appropriate sectors of the

community to assist disabled persons, and the impact of

poverty on a CBR programme.

While it is possible to identify the fundamental

principles of CBR, as described by the WHO, there are

signi® cant variations in implementation across countries.

What has emerged, and is re¯ ected in many of the papers

in this issue, is that the concept of CBR is highly

adaptable and can be developed to meet country-speci® c

needs. It has proved impossible in large developing

countries, such as the People’ s Republic of China, due to

the diŒerences in social systems, economy, and cultural

levels, to implement a uniform model of CBR." #

A study " $ of the impact of CBR on community

attitudes described one of the models of CBR im-

plementation in the People’ s Republic of China. The

CBR programme described is located in an urban

community of Guangzhou City in Guangdong Province,

and reports how `Western ’ techniques are integrated

with traditional Chinese methods of rehabilitation

delivery.

Clearly, one of the fundamental principles of CBR is

that rehabilitation be delivered to the disabled in their

own community, and preferably within their own homes.

In addition the primary deliverer of rehabilitation is a

volunteer, either a family member, or signi® cant other.

Peters et al.," % reporting on the rehabilitation of brain-

injured persons, strongly supported this less restrictive

approach (i.e. no need for a trained health professional

delivering rehabilitation therapy) in the physical and

social context of a disabled person.

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In more recent years CBR has been criticized, generally

on the basis of con¯ icting political views concerning

rehabilitation delivery or through a failure to understand

the CBR concept, or both. Perhaps the most illustrative

example of this can be found in the report by Lysack and

Kaufert. " & These authors compared CBR and inde-

pendent living (IL) and claimed that CBR, being

`imposed ’ by an international agency (the WHO),

developed in the absence of a fully articulated consumer

movement or a fully professionalized and elaborated

system of rehabilitation. This claim may certainly be true

where CBR was introduced into developing countries ;

however, a number of developed countries have also

successfully embraced CBR. Without exception the

developed countries do have consumer movements and a

fully established system for the delivery of rehabilitation

services. For the proponents of both IL and CBR the

purpose of rehabilitation is to optimize the functional

status of the disabled in order that they be independent

active participants in their communities. One, CBR,

describes service delivery ; the other, IL, describes an

expected outcome of service delivery. The IL movement

has its origins in North America sponsored through

consumer movements, whereas CBR has its origins at the

WHO but clearly encourages and encompasses consumer

and community `taking control ’ .

In Hong Kong and the Territories there are 41 public

institutions and 56 outpatient speciality clinics." ’ Despite

these services psychosocial services and CBR were slow

to come. Chau" ( described a Community Rehabilitation

Network (CRN), a novel response to the perceived lack

of community services. Networking is an essential

component of CRN, and the CBR project in Hong Kong

has successfully networked with over 50 hospitals and

rehabilitation agencies. The CRN established a model of

collaboration between the institutions’ patient resources

centres, and community services for the elderly.

Target populations

When one comes to examine the disabilities addressed

through the CBR system a comprehensive variety are

reported in the literature. In some countries speci® c

disabilities have been targeted for the purpose of trialling

CBR and evaluating its impact and acceptance into

communities. Other literature implies that CBR is being

universally used with disabilities, but tends to report the

successes with certain groups of disabled and ignore the

failures, or lack of demonstrable success, with others.

Finally, speci® c disabilities are reported either in a

research context or where a CBR programme has

addressed a single disability. Other research focuses on

CBR outcomes for speci® c sections of the population,

i.e. pre-school children, children, adults, and the elderly.

O’Toole" ) reported the results of a CBR programme

initiated for 53 pre-school children in rural areas of

Guyana. In this study a range of disabilities are reported.

A pre-test ± post-test study showed signi® cant improve-

ment in the children as a result of the CBR training

programme. It is also reported that there were signi® cant

(positive) changes in the attitudes of the parents, the

community and the disabled themselves towards dis-

ability. These latter ® ndings are generally regarded as

essential outcomes for any CBR programme.

Dietary treatment of malnourished children has been

reported by Brown. " *

A more general approach to disability in childhood# !

reviewed recent research carried out in Jamaica and

outlined procedures for, and experiences with, the

medical and psychological assessment of children in a

local CBR programme. While the medical screening was

reported as being satisfactory it was concluded that there

was an urgent local need for the development of valid

psychological assessment. In conclusion, these authors

highlighted some of the limitations of the CBR pro-

gramme and what was required to overcome these

limitations. There was a reported need for attitudinal

change on the part of professionals, changes in the

training of health and education professionals, and a

need for improved linkages and lines of referral.

Finken¯ ugel et al.# " reported on the caregivers (family

trainer) of children with a disability. These authors

examined the impact of a CBR programme in Zimbabwe

on the relationship between caregivers’ appreciation of

CBR and attitude towards various health services, and

between the perceived ability to teach and the expectation

for the child’ s future. This study revealed a signi® cant

correlation between the appreciation of CBR and the

attitude towards various health services, and between the

perceived ability to teach and the expectations for the

future of the child.

A further study # # on disabled children in a CBR

programme examined the extent to which the local

community would support the disabled person in a CBR

programme. Based on the ® ndings of this study,

conducted in Jamaica, the authors questioned the

WHO’ s presumption that the community is a source of

support. However, it should be noted that the WHO

expects a CBR programme to change community

attitudes and result in a greater community involvement

in the programme. It is also expected that community

approval be sought prior to the implementation of a

CBR programme. Perhaps, as these authors point out,

caregivers’ expectations of the community were too high,

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and that support is rejected or not forthcoming when it

does not ® t with the local de® nition of community help.

The impact of CBR as perceived by the disabled

people themselves was reported by Lundgren-Lindquist

and Nordholm. # $ In addition to reporting some epidemio-

logical data for a village in Botswana these authors

found that life satisfaction in disabled persons was high,

although somewhat higher for younger people than for

older ones. Another age diŒerential reported by these

authors was that signi® cantly more younger people

reported that life had improved, while most elderly

people believed life to be worse now.

Chau" ( described the adoption of the CBR approach

to provide rehabilitation services to persons aged 60

years and over. This service, community rehabilitation

network (CRN), provided a range of services which

included information and referral services, educational

programmes and activities, community programmes

including public education programmes, indoor and

outdoor rehabilitation programmes, psychosocial sup-

port and self-help groups, production of printed and

audiovisual materials, networking and advocacy, and

consultancy work.

The eŒectiveness of the CRN approach was evaluated

using a pre- and post-test structured questionnaire." ( The

most notable ® ndings of this evaluation were that the

programme proved to be cost-eŒect (a decrease of more

than 3 days hospitalization within 6 months, reduced

frequency of use of institutional and more costly social

services, and an increased use of volunteer services),

there was a signi® cant increase in empowerment of the

elderly and their families, and a statistically signi® cant

overall increase in the quality of life of the elderly.

Disabilities

The WHO concept of CBR expected that all dis-

abilities identi® ed in communities would be, to a greater

or lesser extent, amenable to rehabilitation.The literature

on CBR indicates that the CBR method of rehabilitation

service delivery has been used with a variety of disabilities

in some communities. In other communities there has

been a restricted number of disabilities addressed. In yet

other communities attempts at rehabilitation have been

focused on a single disability.

Among the most common speci® c disabilities reported

is Hansen’ s disease (leprosy). Gershon and Srinivasan# %

examined the stigmatization associated with leprosy and

concluded that this disease gives rise to social ostracism

and well as signi® cant disability and handicap. These

authors concluded that under no circumstances should

the disabled person be removed from the home en-

vironment, that the community be made `leprosy aware’

and become more involved in the assimilation of the

disabled person. These authors showed that through

such acceptance the disabled person can generate an

income and become an active contributor to his } her

family and community.

That persons with leprosy can become employable,

and therefore contribute to family and community, has

also been examined,# & and it was found that in Bombay

those with leprosy were mostly poorly educated and

lacked special skills. This lack of skill and education

impacted on the disabled person, especially following

loss of employment due to anaesthesia of their

extremities. It was concluded that the only feasible

alternative for re-employing these disabled appeared to

be through a selective CBR programme for leprosy

patients with deformities.

Jagannathan et al. # ’ reported on the cost-eŒectiveness

and suitability of a pilot CBR programme designed to

retrain leprosy patients. Their study examined 20 cured

but disabled patients who were given training in trades

such as bicycle repairing, tailoring, horticultural

spraying, doll making, cane work, cigar making, ® shnet

knitting, and incense-stick making. At the end of a 6-

month training period (some required only 2 months) 17

of the 20 persons had commenced earning an income

through the skills imparted to them. This project yet

again highlighted the need to involve the disabled person

in activities suited to their local community and available

resources.

Often, the prevention and treatment of leprosy

involves complex activities such as nerve compression

and reconstructive surgery. However, Smith # ( suggested

that it may be better to focus on more simple techniques

and approaches which can be implemented through

CBR. Such simple approaches, it is claimed, apply

equally to disease prevention, detection, and to re-

habilitation following more sophisticated treatment.

The rehabilitation of persons who have acquired their

disability through head and brain injury has also been

reported in the literature. One of the earlier reports " %

examined the behavioural rehabilitation of persons who

had sustained traumatic brain injury. The brain-injured

presented with extremes of inappropriate behaviours

which included physical and verbal assault, non-com-

pliance, self-injurious behaviours, elopement, and prop-

erty destruction. These disabled frequently provided

family and health professionals with challenges regarding

treating these behaviours. In fact these behaviours

constituted a major obstacle to rehabilitation. The

traditional treatment of choice has been to reverse the

behaviours in an institutional setting. However, the

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authors did conclude that success in treatment can be

achieved using a CBR approach.

A single case study # ) reported on a 15-year-old male,

injured in a motor-vehicle accident, who was in a coma

for 6 weeks. Five months following the injury he was

discharged to his home to be treated by an intensive

domiciliary programme of CBR supplemented by help

from the local hospital. As a result of this programme the

boy regained function, and it is reported that par-

ticipation in the programme was emotionally rewarding

for relatives, friends and volunteers. It is concluded that

this `home-based ’ management resulted in signi® cant

cost savings to the establish medical system. A later

report # * addressed in more general terms the bene® ts of

CBR for the person with a severe brain injury. In

addition to recognizing the secure, loving environment of

his} her own home this author argued that the person

with brain injury and his} her family, provided with

support and guidance, can eŒectively augment or even

supersede hospital-based rehabilitation. The author

reiterated the cost savings of CBR.

The treatment of continence problems following brain

injury$ ! stated that where these problems are attributable

to psychological factors there is a tendency to avoid or

escape rehabilitation activities. In a case study it was

reported that intervention for such a client was initiated

within an existing CBR programme. It was concluded

that treatment resulted in a signi® cant reduction and

maintenance in escape behaviour; however, no changes

occurred in the patient’ s self-ratings of anxiety.

Variation in the so-called `idealized’ CBR model can

be found throughout the literature and in the ® eld. One

variant that can be found is `home-based ’ care. One

example$ " examined home-based care in late intervention

therapy for stroke patients. This project identi® ed that

participation in social and leisure activities outside the

home was the most promising goal for CBR pro-

grammes. These authors concluded that focusing on such

activities, using non-professional collaborators and

organizations, has a potential for improving the quality

of life of the individual. In fact, these are some of the

aims and objectives identi® ed in the very early days of

the `CBR movement ’ Ð integration into the person’ s

local community and the utilization of individuals and

organizations within that community.

Reporting on the rehabilitation of stroke patients$ # in

CBR programme that authors focused on the early

discharge of stroke patients and conclude that their study

established the feasibility of a CBR approach to the

rehabilitation of stroke patients. Using a randomized

trial patients were assigned to either a special community

rehabilitation programme or a conventional programme

of hospital and community care. After 1 year it was

reported that there were no signi® cant diŒerences in

clinical outcomes except that the group in the con-

ventional programme expressed an increased satisfaction

with hospital care. Again, these authors concluded that a

signi® cant cost saving could be obtained with early

discharge into the community.

The methods of CBR have been employed with

persons with mental health problems. However, it should

be noted that in some countries there is no diŒerentiation

between persons with an acquired psychiatric disorder

and those with a congenital problem, or developmental

disability. One of the earliest studies reported the

potential that CBR presented for the rehabilitation of

persons with schizophrenia.$ $ In those early days of CBR

these authors identi® ed a need for both work and social

rehabilitation facilities and services in the community.

The authors of a report $ % describing the treatment of

mental illness through CBR services argued that the

development of community-based services for these

patients had been slow and piecemeal, and unduly

inhibited by models imported from psychiatric hospitals.

Their conclusion identi® ed one of the major factors

which has inhibited the development of the CBR concept

Ð the attempts to import into the community the

philosophy and practices of institutionalized care. In

many instances institutionalized care cannot eŒectively

be transplanted into a community setting.

The cost of institutionalized care was reiterated in a

study$ & which explored mental health institutions in

Zimbabwe. It was also reported that such institutions

experienced many years of patient stay, even for life, and

as a direct consequence of this there were implications

for cost and quality of services. Quality of services that

could be improved included feeding, clothing, and

providing medical care (maintenance of medication), all

of which could be more eŒectively carried out in the

community rather than in the institutional setting.

A home-based programme $ ’ for developmentally

delayed (mentally handicapped) children and young

adults highlighted how CBR could make e� cient use of

specialist staŒ. While this project was undertaken in

Zimbabwe the author is aware of a similar programme

commenced in the Republic of Singapore as early as

1980. In this previously unreported programme, develop-

mentally delayed children and youths were treated within

their local communities ; however, specialist health

professionals were accessible through the special school

system or workshops managed by the then Singapore

Association for Retarded Children.

The literature also includes reports on the rehabili-

tation of other disabilities using a CBR model. For

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Research base of CBR

example McKenzie $ ( and Bortz et al. $ ) reported on

persons with speech and communication problems.

LeFort and Hannah$ * reported on the outcomes of a

CBR programme which aimed to rehabilitate persons

with low-back injuries and to return them to the

workforce.

It is postulated that education was an important

component of CBR programmes for persons with

rheumatoid arthritis. % ! These authors reported on the

validity of an instrument to measure knowledge about

rheumatoid arthritis and concluded that the instrument,

a questionnaire, was reliable, valid, and sensitive for

measuring the impact of an educational programme.

A frequently ignored population of disabled are

persons suŒering from psychological disturbances and

physical injuries that have resulted from torture or severe

trauma. Reid and Strong % " identi® ed this group of

persons and described the acute and chronic symptoms

that have come to be termed `post-traumatic stress ’ . In

their early report the authors proposed a CBR pro-

gramme which might be implemented to provide a

service for victims of torture and other forms of

organized violence. A subsequent report % # reported on

the implementation of the CBR programme, some of the

sta� ng and service delivery problems, and the charac-

teristics of the ® rst 200 clients.

Locations

CBR programmes have been implemented in many

countries, both developed and developing, in urban and

rural localities, and on all continents. Examples from the

literature to illustrate this diversity in CBR delivery are

given here. CBR programmes have been implemented in

urban centres in Australia # * , % " United Kingdom,) , $ #

Sweden,$ " North America, " & , " * India, # & and the People’ s

Republic of China." # , " $ Examples of CBR in rural centres

can be found in Jamaica,# ! , # # Botswana,# $ , % $

Zimbabwe," ! , # " , $ & , $ ’ , % % , % & the People’ s Republic of

China," $ Indonesia, " & India,# ’ and Papua New Guinea.% ’

Epidemiology of disability

A number of authors have reported using a CBR

approach to obtain estimates of disability. One of the

earlier published papers % ( examined the prevalence of

diseases, impairments, and handicaps in Pakistan. This

prevalence study was conduced as part of a WHO CBR

programme comparing outcomes in a rural village and in

an urban slum. These authors found that the prevalence

of handicap was about half that of impairment, and

found the most common handicaps to be mobility,

occupation, and social integration. There was a slightly

higher degree of handicap in the rural setting. In both

centres the common diseases identi® ed were of the

musculoskeletal system, the ear, and the respiratory

tract. The frequency of infectious, respiratory, endocrine,

blood, and digestive diseases was higher in the urban

centre.

Mitchell et al.% ) reported epidemiological data

obtained from a CBR programme in Guangzhou City,

People’ s Republic of China.

Using the screening methodology recommended by

the WHO a door-to-door survey in Moshupa village,

Botswana, identi® ed 1.4% disabled persons. # $ Among

this group 22% were under 15 years of age and 17%

were over 65 years of age. These authors reported that a

high percentage, 30%, of disabled persons were children

of consanguineal relationships. The majority, 65%, of

the identi® ed disabled had di� culty with mobility and

21% had two or more disabilities.

A survey, % ’ in conjunction with the Papua New Guinea

Institute of Medical Research (PNGIMR), to determine

the prevalence of severe disability, was conducted in the

Tari area of the Southern Highlands Province. This

survey identi® ed a prevalence level of physical disability

(including problems with walking, deafness, and blind-

ness ) of 46 per 10000 (0.46%). Subsequently 54 persons

with a signi® cant physical disability were interviewed in

an attempt to determine their quality of life. This latter

survey found the social and economic situation of the

disabled to be generally good; however, there was a need

for basic mobility aids. These authors concluded that

disabled persons and their families did not need extra

knowledge about how to care for their disabilities, and

that a formal CBR programme would be inappropriate.

This conclusion re¯ ects some degree of ignorance of the

CBR concept. A CBR programme is not meant merely to

provide care for the disabled and their families but

rather, using family and community resources, to

rehabilitate the disabled person, i.e. optimize his } her

functional and social abilities. In addition, the conclusion

regarding an established need for CBR was reached on

the data derived from interviewing less than 50% of

those with a `signi® cant’ physical disability.The question

arises would CBR be appropriate for those with less

`signi® cant’ disability, including the psychiatrically,

emotionally, and congenitally disabled?

Another epidemiological study % * employed the WHO

screening questionnaire $ to identify persons who

reported health problems aŒecting their functional

ability. The ® ndings of this survey were con® rmed in a

follow-up interview. This second phase of the identi-

® cation of disability in a community is an essential

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component of the WHO model for CBR. However, it

was pointed out that the cost of this validation

component can be prohibitive and is often omitted from

low-budget programmes. Costs associated with vali-

dation include salaries for medical and rehabilitation

experts, transport to remote communities, and accom-

modation costs. In many CBR programmes there is a

`trade-oŒ’ between cost saving and minimizing false-

positive and false-negative rates.

As recommended by the WHO, the ® rst phase in

establishing a CBR programme is to determine the extent

of disability in the target community. Such a stage was

carried out in order to establish a CBR programme in the

rural district of Lezha (Albania). This study & ! employed

the WHO questionnaire and found that the prevalence of

disabled persons under 18 years of age was 5.86 per 1000

and the most frequently diagnosed disability was

associated with cerebral palsy, followed by develop-

mental disability and deafness. It was concluded that a

CBR programme could improve the self-su� ciency of

this group and lead to an early school attendance.

The high cost of validating prevalence data reported

from various CBR programmes has impacted on the

quality and validity of these data. In many projects,

identi® cation of the disabled, using the WHO protocol,

is carried out by lay persons with little or no training in

the health sciences.

Conclusion

There are four readily identi® able features of CBR on

which research and} or evaluation might focus. In the

listing of these areas there is also some sense of priority ;

however, there is an urgent need to address all four and

other aspects of CBR using the scienti® c approach

embedded in research } evaluation methodologies. The

four potential priority areas for research are :

(1) Service delivery system Ð the way in which train-

ing or services are being provided by the CBR

worker (the local supervisor or rehabilitation

worker) to the disabled person at the community

level. Speci® c issues to be examined might include

(a) utilization of the primary health-care worker ;

(b) CBR worker based in the community vs.

rehabilitation personnel coming in from the

outside to provide training;

(c) training family members to train disabled

relatives;

(d) the relationship between the local supervisor

and the family trainer, and between the local

supervisor and the disabled person.

(2) Technology transfer Ð this would include the

technical skills that the local supervisor should

possess. Speci® c issues might include:

(a) the eŒectiveness of the WHO manual;

(b) how can the WHO manual be used in

conjunction with other manuals;

(c) teaching technical skills to the local supervisor

at minimum cost and in the shortest possible

time ;

(d) what and how much skill should the CBR

worker have;

(e) optimizing the acquisition of skills on de-

signing, producing, and maintaining appro-

priate aids;

(f) packaging `rehabilitation technology’ other

than in a written form;

(g) identifying various disabilities through the

application of simple detection techniques.

(3) Community involvement Ð this is a vital ingredient

in the implementation of a CBR programme.

Training of the disabled person should be the

concern not only of the family trainer and CBR

worker but also of the community in which the

person lives. This might involve the following:

(a) assessing change in attitude of the community

towards disabled people;

(b) mobilizing various sectors of the community

to support and assist disabled people;

(c) identifying and utilising community resources

in the CBR programme ;

(d) encouraging the community to undertake the

maintenance of the programme ;

(e) impact of poverty on the programme and the

use of available community resources.

(4) Organization and management Ð CBR deals with

a lot of people. The local supervisor, family

trainer, other members of the family, the disabled

person, and the community should all participate

actively in the total rehabilitation process. Because

people are the essential component of CBR,

organization and management play a signi® cant

role in ensuring an eŒective CBR programme.

Management occurs both on the horizontal level

(local supervisor, family trainer, disabled person,

community), and the vertical level (referral struc-

tures from the town, province, district, national,

and international levels). Priority research areas

might include:

(a) identi® cation of the organizational model

which can best be adapted to many situations;

(b) linkages within the referral network to the

horizontal structure ;

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Research base of CBR

(c) identi® cation of appropriate personnel at and

for each level;

(d) the role of the private sector in the man-

agement of a CBR programme when the

programme is a government undertaking;

(e) the importance of the disabled persons as-

suming leadership roles in the management of

rehabilitation programmes.

The above list is not meant to be exhaustive, and clearly

it is not. For example, the economic aspects of CBR

should be examined in a scienti® c way and might include

cost-eŒectiveness of the many facets of rehabilitation

delivery using a CBR model. Other research issues might

examine the training of the middle-level health workers ;

does the CBR concept require specialist allied health

professionals or should it focus on training a multi-

functional therapist ? What is the best } preferred mode of

training such people (tertiary, technical, on the job,

sandwich, etc) ?

Little quality research on CBR has been placed in the

mainstream of scienti® c literature. some material can be

obtained from WHO reports and workshop summaries ;

other sources include International Labour Organization

(ILO) publications, Non Government Organization

(NGO) annual reports, and reports from government

instrumentalities. There is a considerable amount of raw

material available to researchers at each of the three tiers

of CBR delivery. The challenge is to access and report in

an acceptable scienti® c manner the data from this

material.

CBR research can only bene® t from moving into the

mainstream of reporting and public scrutiny. This

exposure will serve to draw attention to the technology

and interest in its outcomes. At the same time it is

obvious that this exposure is a two-edged sword.

Research methodology will be critiqued, the objectivity

of the researcher assessed, and conclusions examined in

the light of evidence presented. Outcomes may be adverse

and these should be reported as clearly as should

supportive data. No experienced reviewer anticipates a

continuous success story and indeed would be justi® ably

sceptical if this were the case. There are risks in this

process but clearly the CBR movement has reached a

su� cient stage of maturity to accept this challenge.

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